17. Have you ever been told you have liver trouble? Cirrhosis? (Y/N) Score [select name="17" value="No=0|Yes=2"]

18. After heavy drinking, have you ever had Delirium Tremens (D.T.s), or severe shaking, or heard voices, or seen things that really were not there? (Y/N) Score [select name="18" value="No=0|Yes=2"]

19. Have you ever gone to anyone for help about your drinking? (Y/N) Score [select name="19" value="No=0|Yes=5"]

20. Have you ever been in a hospital for your drinking? (Y/N) Score [select name="20" value="No=0|Yes=5"]

21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward in a general hospital where drinking was a part of the problem that resulted in hospitalization? (Y/N) Score [select name="21" value="No=0|Yes=2"]

22. Have you ever been seen at a psychiatric or mental health clinic, or gone to any doctor, social worker, or clergyman for help with an emotional problem, where drinking was part of the problem? (Y/N) Score [select name="22" value="No=0|Yes=2"]

23. Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages? (Y/N, if yes how many times __) Score [select name="23" value="Never=0|Three=6|Twice=4|Once=2"]

24. Have you ever been arrested, or taken into custody even for a few hours, because of other drunken behavior? (Y/N, if yes how many times __) Score [select name="24" value="Never=0|Three=6|Twice=4|Once=2"]

1. Do you feel you are a normal drinker? (By normal, we mean you drink less than or as much as other people.) (Y/N) Score

2. Have you ever awakened the morning after some drinking the night before and found you could not remember a part of the evening? (Y/N) Score

3. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking? (Y/N) Score

4. Can you stop drinking without a struggle after one or two drinks? (Y/N) Score

5. Do you ever feel guilty about your drinking? (Y/N) Score

6. Do friends or relatives think you are a normal drinker? (Y/N) Score

7. Are you able to stop drinking when you want to? (Y/N) Score

8. Have you ever attended a meeting of Alcoholics Anonymous (AA)? (Y/N) Score

9. Have you gotten into physical fights when drinking? (Y/N) Score

10. Has your drinking ever created problems between you and your wife, husband, a parent, or other relatives? (Y/N) Score

11. Has your wife, husband (or other family members) ever gone to anyone for help about your drinking? (Y/N) Score

12. Have you ever lost friends because of drinking? (Y/N) Score

13. Have you ever gotten into trouble at work or school because of drinking? (Y/N) Score

14. Have you ever lost a job because of drinking? (Y/N) Score

15. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking? (Y/N) Score

16. Do you drink before noon fairly often? (Y/N) Score

17. Have you ever been told you have liver trouble? Cirrhosis? (Y/N) Score

18. After heavy drinking, have you ever had Delirium Tremens (D.T.s), or severe shaking, or heard voices, or seen things that really were not there? (Y/N) Score

19. Have you ever gone to anyone for help about your drinking? (Y/N) Score

20. Have you ever been in a hospital for your drinking? (Y/N) Score

21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward in a general hospital where drinking was a part of the problem that resulted in hospitalization? (Y/N) Score

22. Have you ever been seen at a psychiatric or mental health clinic, or gone to any doctor, social worker, or clergyman for help with an emotional problem, where drinking was part of the problem? (Y/N) Score

23. Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages? (Y/N, if yes how many times __) Score

24. Have you ever been arrested, or taken into custody even for a few hours, because of other drunken behavior? (Y/N, if yes how many times __) Score